What is poorly functioning Asperger's

What role does the family doctor play?

For children and adolescents with autism spectrum disorders (ASD) there is a branched network of autism centers, autism officers, school attendants, vocational training centers and others. a pretty good care system. In their practice, however, general practitioners are more likely to have to do with the care of adults with ASD. In the following we describe the challenges associated with this and how general practitioners can cope with them.

ASA can lead to sometimes severe psychosocial problems, high levels of suffering and numerous secondary stresses even in adulthood. The comorbidity rate of psychiatric illnesses is> 50% [6, 9]. Nevertheless, most patients with ASA in adult psychiatry are still treated with incorrect or incorrectly weighted diagnoses - often unsuccessfully.

ASS in the general practitioner's practice

Adults with ASD play a role in general practice in different ways. In broad outline, the following three approaches are likely to be most relevant:

1. Due to the significantly increased diagnosis rate in children and adolescents, an increasing number of diagnosed autistic people will be treated by general practitioners who will then - in the best case - already have a largely functioning support network. For these patients, it is primarily a question of good coordination with the support network (autism centers, school attendants, etc.) and adequate handling of them in the context of the treatment of comorbid somatic diseases.

2. Since highly functional forms of autism in particular were not included in the international classification systems until the 1990s, there is a relevant diagnostic gap for people born before 1975. Here - despite the often very clear behavioral abnormalities - the diagnosis of ASA was often neglected due to the lack of a diagnostic category (see case study). For this reason, there are always adults with ASD in general practitioners who - despite clear symptoms - were never diagnosed.

3. Due to the increased media coverage of the topic, more and more people come to the consultation who suspect that they or their partner might have ASD. These three access routes result in the challenges that the attending general practitioner is faced with more often: How do I adequately deal with adults with ASD? How do I make the initial suspicion of ASA? Where can the patient turn for diagnostics, advice and therapy?

False stereotypes and refutations about autism
"Autistic people have no feelings"
  • People with ASD naturally have feelings, only these are expressed less clearly with facial expressions and gestures.
"Autistic people have no empathy"
  • People with ASD are less able to empathize with their counterparts and often do not recognize the feelings of their fellow human beings by facial expressions, but they do feel empathy when someone experiences suffering.
"Autism = Psychopathy"
  • According to current usage, the term psychopathy describes a developmental disorder with a lack of compassion and compassion, as well as a reduced response to anxiety-inducing stimuli. This should not be confused with ASS.
"Autism Is Caused By A Fridge Mother"
  • This early theory suggested that the mother's hypothermic behavior led to autism. It has long been considered refuted.
"Autism Is Caused By Vaccinations"
  • There are many differentiated studies on this, all of which came to the conclusion that autism is not caused by vaccinations.
"Autism can be treated with gluten-free foods or other diets"
  • While there are always individual case reports in which a significant improvement in symptoms is described with a change in diet, no dietary measure has so far shown a statistically significant effect in controlled studies. The only exception is the not yet replicated finding that a substance contained in broccoli should improve the symptoms of autism [11].

Etiology, pathogenesis

Based on twin studies in particular, it is assumed that the cause of autism is mainly genetic. Pathogenetically, it is discussed that the network structure of the brain differs in that the local (short-range) connectivity is increased, while the global (long-range) connectivity is reduced [7]. The theory of the deficit of the "theory of mind" in autism assumes that people with ASD have a reduced ability to "mentalize" the inner states of other people, i.e. less automatically represent and respond to feelings, thoughts, intentions and prior knowledge of their fellow human beings [2 ]. Box 1 summarizes some of the false stereotypes and disproved theories that patients occasionally ask their doctors about.

Patient P. (49 years old) is being treated for "burn-out" and "social phobia" because she is increasingly unable to cope with social situations at work and has "collapsed" several times. During behavioral treatment of the social phobia with exposure therapy, her psychopathological findings had deteriorated significantly, including hours of dissociation-like states with mutism.

The patient looks a bit peculiar in contact and, when asked, reports on sophisticated conscious strategies for controlling social behavior: Between the ages of 20 and 30, she learned when and how to smile, when to nod, when to "M-hm" say when to speak up in what kind of conversation, when to look at someone and when to look away again. It was very helpful to learn by heart the etiquette that her mother-in-law recommended to her "because of her bad behavior" and to take acting lessons.

She also learned to consciously interpret certain features in facial expressions, gestures and posture. In the end, she consciously worked on being more flexible, eating more varied and, for example, in public. B. not to "rock" back and forth with the upper body. In this way she developed from the total outsider she was as a child to a "member of good society". Ultimately, however, this social behavior has always remained a "facade" and "extremely exhausting". Now she simply can no longer: In terms of content, she can still manage at work, but in social terms she feels substantially overwhelmed and permanently overloaded with stimuli.

The differentiated 75-year-old mother of the patient describes numerous abnormalities typical of autism from the patient's childhood, such as a lack of eye contact, deficits in the theory of mind, inability to establish contact with peers, and a lack of flexibility in changing processes with excessive fits of anger, which at the time - despite multiple visits to psychologists - did not lead to a diagnosis.

The diagnosis of ASD (ICD-10: F84.5) is made because there were clear autistic symptoms in elementary school age and the current level of suffering can be attributed to them. From a therapeutic perspective, the inclusion of ASA diagnosis in "burn-out" treatment has far-reaching implications. Case study (from [8], with the kind permission of the editor)

Diagnostic criteria

While the diagnosis in childhood and adolescence is made using standardized observation and anamnesis instruments, the diagnosis in adulthood is primarily clinical, especially with reference to the developmental history and with the help of personal and external anamnesis, neuropsychological examinations and psychiatric findings. Screening instruments in adulthood include: The SRS-A (Social Responsiveness Scale for Adults, [4]) and the AQ (Autism Spectrum Quotient, [3]) are used in people without intellectual disabilities, but the specificity is very low, which is why the results are interpreted with great caution must [1]. In the event of clinical suspicion and a positive screening result, the person concerned should be referred to a body specializing in the diagnosis of ASA [1]. The diagnostic criteria for autism spectrum disorders according to DSM-5 are summarized in Table 1 and provided with examples of common symptoms. A suspected diagnosis can result from this and / or if, for example, the rhythm of the conversation is very irrelevant, if rules of courtesy are (unintentionally) not observed, if there is an obsessive uniformity of the structure of life, if a person from their environment is "always different from others "is perceived or feels" landed on the wrong planet ".

In reality it turns out - z. B. in the case of suspected diagnoses or the desire for additional treatment by a doctor experienced with autism - sometimes difficult to find suitable contact persons. It is advisable to inquire in detail on site who feels responsible and has the necessary experience to carry out screening examinations or a complete diagnosis. In some areas resident psychiatrists and psychotherapists can be contacted, in others the specialists do not feel competent. Sometimes the local autism center can help. There are extremely few agencies specializing in the diagnosis of autism in adulthood, so waiting times of 12 to 24 months can be expected. For the patient, however, the effort is worthwhile in most cases: A correct diagnosis usually has positive implications, because it enables an adequate understanding of the autistic characteristics and the resulting psychiatric symptoms, as well as an appropriate and understanding approach.

Therapy and handling

Since the "autistic core syndrome" is not "curable", the therapeutic approach focuses on the one hand on comorbid diseases (e.g. recurrent depressive disorders) and on the other hand on dealing with the symptoms of ASA [10]. Psychoeducation (what is autism? How do the others "work" and their numerous "social rituals"?) And the practice of social situations play a major role in this [5]. The treatment of comorbid diseases should be modified according to the autistic basic structure [12]: For example, depressed patients with ASA should by no means be encouraged to spend many hours among people. People with ASD just feel overwhelmed and overstimulated. Some tips for dealing with adults with ASA are summarized in Box 2.

Advice on the practical handling of adults with ASD
procedure
  • The conversation should follow a recognizable routine
  • Don't be too spontaneous when dealing with patients at first
  • Transparency: inform the patient about your plans early and precisely
Language, communication
  • Speak clearly and directly and neither too metaphorically nor too politely-indirectly
  • Ask closed and clearly focused questions, do not start with open questions ("What brings you to me today") or questions about internal states ("How is your mood today?")
  • Include breaks for questions
  • Explain that misunderstandings are common, ask until you understand the patient and, conversely, ask if everything has been understood
  • Avoid or identify ambiguities, jokes, idioms
  • Be prepared for the fact that you will not always get an answer immediately (extended response latencies)
acceptance
  • Do not be disappointed if the patient does not recognize you or greet you outside of the consultation hour (often prosopagnosia is present)
  • Do not be surprised if your patient cannot interpret your facial expressions or does not understand body language messages
  • Do not take undiplomatic expressions, directness or a seemingly lack of sensitivity and lack of eye contact personally. Don't automatically interpret insensitive behavior as "narcissistic"
Sensory peculiarities
  • Avoid unexpected contact, announce physical examinations or treatments and explain them in detail.


1. AWMF Online (February 23, 2016). Autism Spectrum Disorders in Children, Adolescents and Adults Part 1: Diagnostics. Accessed December 28 2016 from http://www.awmf.org/uploads/tx_szleitlinien/028-018l_S3_Autismus-Spektrum-Stoerungen_ASS-Diagnostik_2016-05.pdf.
2. Baron-Cohen S (1991) Precursor to a theory of mind: Understanding attention in others. In: Whiten, A. (Ed.) Natural theories of mind: Evolution, development and simulation of everyday mindreading. Oxford 233-251
3. Baron-Cohen S, Wheelwright S, Skinner R, Martin J, Clubley E (2001) The autism-spectrum quotient (AQ): evidence from Asperger syndrome / high-functioning autism, males and females, scientists and mathematicians. Journal of Autism and Developmental Disorders, 31 (1), 5-17
4. Bölte S, Poustka F (2008) SRS: Scale for recording social reactivity. Dimensional autism diagnostics, Hogrefe, Göttingen
5. Ebert D, Fangmeier T, Lichtblau A, Peters J, Biscaldi-Schäfer M, Tebartz van Elst L (2013): Asperger's autism and highly functional autism in adults. The therapy manual of the Freiburg Autism Study Group. Hogrefe, Göttingen
6. Lehnhardt F-G, Gawronski A, Volpert K et al. (2011) The Psychosocial Functional Level of Late Diagnosed Patients with Autism Spectrum Disorders - a retrospective study in adulthood. Advances in Neurology • Psychiatry, 80 (02), 88–97
7. Picci G, Gotts SJ, Scherf KS (2016) A theoretical rut: revisiting and critically evaluating the generalized under / over-connectivity hypothesis of autism. Dev Sci 19 (4): 524-49
8. Riedel A (2016). Clinical diagnosis of and experience from the consultation for autism spectrum disorders. In: L. Tebartz van Elst (ed.). Asperger's Syndrome and Other Highly Functional Autism Spectrum Disorders, 2nd edition, Medizinisch Wissenschaftliche Verlagsgesellschaft, Berlin
9. Riedel A, Schröck C, Ebert D, Fangmeier T, Bubl E & Tebartz van Elst L (2016) Unemployed people with above-average education - education, employment relationships and comorbidities among adults with highly functional autism in Germany. Psychiatric Practice, 43, 38-44
10. Riedel A, Clausen J (2016) Basic Knowledge: Autism Spectrum Disorders in Adults. Psychiatrie Verlag, Cologne
11. Singh K, Connors SL, Macklin EA, Smith KD, Fahey JW, Talalay P, Zimmerman AW (2014) Sulforaphane treatment of autism spectrum disorder (ASD) Proc Natl Acad Sci U S A, 111 (43) 15550-5
12. Tebartz van Elst L, Pick M, Biscaldi M, Fangmeier T, Riedel A (2013) High-functioning autism spectrum disorder as a basic disorder in adult psychiatry and psychotherapy: psychopathological presentation, clinical relevance and therapeutic concepts. European Archives of Psychiatry & Clinical Neuroscience, 263, Suppl. 2, 189-96
13. Tebartz van Elst L (Ed.) (2016) The Asperger Syndrome and Other Highly Functional Autism Spectrum Disorders, 2nd edition. Berlin: Medical Scientific Publishing Company.




Senior physician at the Center for Mental Illnesses (Department), Clinic for Psychiatry and Psychotherapy, University Hospital Freiburg, Medical Faculty Albert-Ludwigs-University Freiburg, Germany

Conflicts of Interest: The author has not declared any.